MENTORING ACTIVITIES IN STRENGTHENING OF DELIVERY POINTS

MENTORING ACTIVITIES IN STRENGTHENING OF DELIVERY POINTS



Introduction

A comprehensive district strategy that aims at addressing the capacity gaps to enhance the efficiency, effectiveness and equity in RMNCH+A services is needed in the district.

It is essential that we build the capacity of the public sector facilities by understanding the critical service and supply gaps and charting a plan of action with clear time-line to address the gaps.


Zooming in on the health system at the facility level, ensuring supply refers to distributing essential resources (HR, infrastructure, drugs and consumables required, etc.) for providing quality services according to the expected level (L1, L2, or L3) of a facility. Facility-level supply improvement consists of two approaches-strengthening and activation of facilities.



Strengthening

Strengthening refers to improving the availability of key services and resources such as required RMNCH+A services, trained HR, commodities and logistics etc. at current delivery points to ensure that none of the delivery points (facilities conducting more than 3 deliveries per month) any longer suffer from gaps that may compromise the quality of services. For example, in the provision of maternal health services, facilities that need to be strengthened are defined as those conducting deliveries, yet lack the critical requirements to provide the services- SBA deliveries, BEMONC services (12), and CEmONC services (L3) (Table YY) commensurate with facility type and level to prevent and treat maternal and newborn health complications. Strengthen' refers to bolstering existing services - availability and quality as a means to increase utilization of services.


Table 8: Defined minimal 'Signal Functions' that health facilities should provide

Source: MNH Tool-kit, Nov 2013


Facilities need to be strengthened according to their expected status (L1, L2, or L3 the definition of Delivery Points is given in Figure BB) and the caseload (average number of deliveries per month). The expected status will help determine the kind of services that a facility should provide and the caseload will help determine the quantity and type of resources required for optimum operations at the facility.



The above example on 'Signal functions' is one example that helps demarcate the type of services that should be available at a particular facility, i.e. all BEmOC Services should be available at all L2 facilities while all CEmOC services should be available at all L3 facilities. Another example would be the demarcation of Family Planning (FP) services according to the level of facility Table AA lists down the type of FP services by type of facility.


Other such examples to help understand the types of services by level can be found in the 'Maternal and Newborn Health Toolkit, prepared by the Maternal Health Division, Ministry of Health & Family Welfare, dated Nov, 2013.


Table 9: Family planning services by level of facility

Source: MNH Tool-kit, Nov 2013


Definition of Delivery points - Source: MNH Tool-kit, Nov 2013


L1: Sub centers and all health units which have an average monthly delivery load of >3 but <10. All active sub-centers and sub-optimally active PHCs, CHCS, and DCHS are included in this


L2- All health facilities excluding sub centers are considered L2 which have average monthly delivery load of 10. All active PHCs, CHCS, DCH, DWH, BMC, other hospitals are included in this which are conducting 24x7 services and not conducting C-sections


L3- only CHCS, Medical colleges and district level facilities are considered L3 which are providing facilities for C-Sections and blood storage/transfusion facilities. BMCs with C-Section facilities are also included in this category.


Strengthening also refers to the up-gradation of a facility from L1 to L2, or from 12 to 13 according to the need of the population in a district or a block. A district with a population of 20 lakhs needs 4 L3s in the district (at the rate of 1 L3 per 5 lakh population as per Gol guidelines) and if it has, for example, 2 13s (including DH) in the district then over the course of 2014- 17, the district should try and upgrade at least 2 of its current 12s to L3s.


Strengthening also requires ensuring that the resources available at a facility is commensurate with the caseload of a facility. The caseload at a facility significantly influences the HR, procurement, and infrastructure needs.

For e.g. a facility conducting 300 deliveries, a month will require more Staff Nurses, more Misoprostol, more Radiant Warmers, and more access to power than a facility conducting 50 deliveries.

These requirements can be found in the tool-kit and can vary as per the needs and priorities of the facility. The requirements as per caseload should be calculate in consultation with the facility staff and keeping in mind the Gol guidelines.



Nurse mentors' role in supporting the strengthening

Nurse mentors can play a significant role in strengthening of facilities in their blocks by helping the staff at a facility in understanding and acknowledging the service gaps, supporting in building an 'action plan for addressing the gaps and in helping the facility in-charge raise issues related to non-availability to the concerned officer at district level at the right time.


The sequence of steps that the Nurse mentors should follow to facilitate strengthening and activation is detailed below:


Step 1: Understand the current level and target level of all facilities in the block

The first step towards facilitating the activation and strengthening of facilities will be to thoroughly understand the current level of all delivery points in the block, the expected level of the current delivery points by the end of the year (or by the end of 3 years), and list down the facilities which need to be 'activated' within that year.


The expected level of current delivery points, if they are already being upgraded, and the delivery points, which need to activate, have already been identified by the districts /blocks keeping in mind the following:


Need of the population and priorities of the situation: The number of L1, L2, and L3 facilities required to depend on the total population, the current percentage of institutional deliveries, the 3-year targets in terms of percentage of institutional deliveries etc.


Geographic distribution of delivery points: In order to reduce time of care, the Gol mandates that delivery points should be geographically well distributed and the district has kept this in mind before selecting the delivery points for activation and strengthening


Situation analysis: Current availability of key resources such as HR, infrastructure, training etc. helped the districts identify which facilities can be upgraded or activated and how can they be phased out.

For e.g. a non-delivery point APHC with required staff available can be taken up for activation before an APHC which doesn't have the required staff.



The list of delivery points selected for strengthening/up-gradation and activation per block should be available with the DPMU, Block officials, and the TSU district and block staff.

All facilities identified for strengthening and activation will fall in one of the following categories:


  • L3 requiring strengthening of services
  • L2 which needs to be upgraded to L3
  • L2 requiring strengthening of services
  • L1 which needs to be upgraded to L2
  • A non-delivery point that needs to be upgraded to L1 (orL2)


Step 2: Conduct gap analysis using Self-assessment tools

Once the expected status of a facility is known, the facility staff needs to be supported in doing a 'self-assessment' to identify the gaps in services, resources etc. The tool will help identify the critical gaps against the requirements of a facility as per the expected level of the facility and caseload. For e.g. if a facility which is currently operating as a L2 facility has been selected for up-gradation for year 2014-15 then one of the critical gapsas per the expected level can be availability of Blood storage unit'. Most of the critical gaps related to resources, knowledge, and quality of services. Gaps canbe relate to systems such as HMIS, which has been explain in the Part D of the manual.



Step 3: Make an 'action-plan' that intends to address gaps in a timely manner

The last and most critical step to support strengthening and activation of facilities is to help the facility staff in making a detailed action plan that lists down the type of gap, reason for the gap, possible solution, time-line for addressing the gap and identifies the person responsible for ensuring that the gap is address in a timely manner.



This can be accomplished by using the 'Action plan template', which has been explained in section EE. It is important that the Nurse mentor keeps following up with the relevant staff members who are responsible for a particular type of gap and help them in addressing the gap, if required.


The Nurse mentor should also help the facility in-charge in raising the issue of non-availability of key resources to the block/district officials at the right time.



To facilitate the strengthening and activation of facilities, it is very important that the facility staff and the block/district staff are aligned on the priorities of the facilities and are fully aware of the level at which a facility needs to be. They should work together to identify and acknowledge the needs of a facility and agree on an approach that is not only inclusive but also achievable within the set time-period.

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